Paediatric Spine and Scoliosis
What is Scoliosis?
Scoliosis is a bend in the spine. In this condition, the spine becomes bent much like a spiral staircase. It is observed that it occurs in a very mild nature in up to 2 % of children, and is more often seen in females. Most of the milder one go undetected and may never become severe enough to warrant any treatment.
How is Scoliosis usually detected?
Scoliosis is usually detected more in females than in males. It is usually observed in three age groups. The detection and the features depend on the type of scoliosis.
What are the types of Scoliosis ?
Broadly, there are three types:
Idiopathic
No medically proven cause detected - but this is the most common. It is subdivided into three common types based on the age it is detected in.
- Infantile ( Seen soon after birth or in the first few years of life )
- Juvenile / Early Onset Scoliosis ( from 4 - 10 years of life)
- Adolescent: During adolescent age group and this is the most common Ideopathic form.
Congenital ( Due to malformation of vertebra bony structure)
- This may be associated with other birth defects like other bony anomailes, many skeletal syndromes, hear defects, spinal cord defects etc.
Neuromuscular
- This is seen in conditions in children with neurological problems like Cerebral Palsy, Polio, Spinal Muscular Dystrophy, Muscular Dystrophies etc.
How is the adolescent type usually detected?
Usually it comes to light just before the child achieves growth spurt / puberty. The mother / relative may notice that one shoulder may be at a different level than the other. There may also be an evident hump on the side of the rib cage. This will become even more evident when the child bends down. The trunk may be shifted one side / the hip might be raised. Rarely there may be malformation of the chest and difficulty in breathing on exertion. This usually occurs in patients who come late and the bend is very stiff and has progressed too much.
The options available for treating this depend on the type of scoliosis, the associated lesions, and the severity of the curve.
Broadly, the options of treatment in any kind of scoliosis are :
- Careful Observation and Follow up
- Physiotherapy and Exercise coupled with Observation
- Bracing in association with the above said methods
- Surgical treatment
The entire range of options can be exercised in Idiopathic Variety of Scoliosis. The neuromuscular scoliosis is usually not amenable to physiotherapy / bracing and usually requires surgical care if it exceeds certain prescribed limits.
Physical Therapy / Exercise / Yoga can play an excellent supporting role in delaying a curve progression and maintaining curve flexibility. It is currently unclear from medical research whether they really do affect the long term curve severity. However, we recommend such treatment for most patients who come early as it helps maintain the trunk muscle strength, balance, and flexibility.
This form of treatment can be coupled with bracing to yield good results in many mild cases of scoliosis.
In bracing, a custom trunk mould of the child is taken by the orthotist on a table with traction and padding pressures so that the curve is corrected from outside as much as possible. The brace tries to hold the trunk in this corrected position. It is made of high strength plastic material which is heat mouldable for minor adjustments later.
In the most common type of brace called the underarm brace (Boston Brace), the entire trunk is converged from the level of underarms to the hip. There is a opening with a strap in the midline which helps keep the two halves bound together. The inner side is carefully padded all around so that the bony areas which it fits snugly don’t rub and cause pressure sores on the skin. There are specific corrective pads at various predetermined points which help push the curve in to some correction. The areas where the pads are kept depends on the type of curve and the severity.
The type of brace and the extent depends on the clinical curve pattern and the areas affected by the scoliosis. In some case where it extends very near to the base of neck, it may be necessary to extend the brace up to the chin. This type of brace is called Milwaukee brace. Unlike the underarm brace which can be concealed under the dress and a child can wear unnoticed, the chin support and the head pads of Milwaukee are visible outside.
It depends on the severity of the curve and the type of scoliosis. If the curve is stiff and severe and the child is too old or if it is caused by neurological / birth defects, bracing is usually not effective. If on the other hand it is an idiopathic curve, in a young child, with lot of growth remaining, it is worth a trial. There is no real assurance that even in this case that the brace may control it. Medical research is full of conflicting claims on the efficacy of the brace. Even though not proven categorically, in general, the practice is to recommend brace wear for 20 - 22 hours a day.
In an Indian scenario there are several problems and practical aspects that prevent successful bracing. Western medical literature places a lot of emphasis on bracing. This is however not so in India.
Some reasons are:
- Children report very late for treatment and many of them cannot be braced as the curve is much more severe. This is because in the western world there is an effective Scoliosis screening programme in schools which helps detect it very early.
- Due to several social and compliance issues this child will refuse to wear the brace for 20 - 22 hours, thus reducing the effectiveness.
- Orthotic techniques, material quality are much lower than in the western world. Trained orthotics in spine bracing are not available widely.
- The brace will need frequent follow up to do some maintenance work on it due to wear and tear. Parent find this time consuming and costly. This involves travel from far off places to the centre and waiting for the brace to be mended. Many of them find it beyond their means to do so and slowly get disillusioned.
The usual surgery for adolescent scoliosis is called fusion surgery. It is an attempt to correct the bend in the spine as much as it safely allows, balance the shoulders and hips and try to fuse the individual vertebrae to one another so that in the long term the correction that has been achieved is maintained. Initially, to hold the vertebrae in the corrected positions, we use metal screws and long rods.
Surgery for scoliosis is a major undertaking, but it can usually be performed without much complications. Aside from the usual problems relating to anaesthesia, post operative infections etc., the more specific problems relate to injury to the spinal cord when a bent spine is straightened out. Fortunately this kind of injury is rare. There are several advancements that have been made like intraoperative spinal monitoring and wake up test that can be safely used to minimise this possibility and to detect it early. The long term complications relate to non - fusion of the bone which can result in pain or breakage of the implants. These may need a second surgery to attempt a bone grafting into that area.
There are many other types of paediatric spine disorders. Some of them are:
Spinal Bifida / Meningomyelocele:
This is due to a failure of formation of the midline of spine. This results in the spinal cord lying exposed outside in very severe cases. In milder cases, the spinal cord will be under the skin. There may be a tuft of hair or some 'skin marker' that is indicative of underlying problem.
Congenital Kyphosis:
This results in excess hunch back and is caused by a birth defect. This often requires surgical correction as it can cause pressure on the spinal cord and neurological problems.
Scheurmann's disease:
This is usually seen in the adolescent age group. The child usually presents with rigid hunch back and pain. Most cases achieve some benefit with conservative care but if the hunch is more than a prescribed limit and pain is severe they may require surgical intervention.
Neurofibromatosis:
This condition is due to a genetic cause. The child will have multiple nerve tumours that erode the bone and cause severe scoliosis and kyphosis (hunch back). Usually the nerve is intertwined with the bone and bone is very weak. Surgical correction is usually required for this condition, even though the complications are high when compared to idiopathic scoliosis surgery.